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Best Practices

June 26, 2018 by Julieta Benavides

Rhomboids: The Case For Strengthening

As I mentioned in my last post, neck and shoulder pain are among the most common reasons for clients to seek out massage therapy.  In a perfect world, we would be able to engage in a wider variety of movements as well as getting in MORE movement throughout the day, including dynamic stretching.  Recruiting all of the muscles in non-repetitive ways is easier on the body and should keep musculoskeletal complaints to a minimum.  However, this is not always possible.  Sometimes we just need simple stretches or exercises to help us “do the best we can”, since we spend too much time in one static position given our biomechanical environment.  It is worth repeating that there is no “ideal” posture, but some postures are much easier on the body than others.  Particularly in the case of forward head posture, alignment does matter.  Barring injuries and other acute situations, the majority of us with just the standard discomforts due to forward head posture could benefit from three basic concepts:

a) getting the head aligned over the neck (not in front of it),

b) stretching the anterior musculature, and

c) strengthening the posterior musculature.

There is obviously A LOT more to consider, but these little basics are a great start.  I have already written about getting the head on the neck and stretching the muscles in the chest and on the anterior part of the shoulder blade.  The next step is strengthening the muscles in the back of the neck and shoulders that are being pulled taut and causing discomfort, specifically the rhomboids and the upper trapezius.  This will be a two part blog post – the first will address the rhomboids and the second will address the upper trapezius.  I will give some basic suggestions, but please CONSULT WITH AN EXERCISE PROFESSIONAL prior to trying any of these exercises if they are new to you or if you have injuries.

RHOMBOIDS: ANATOMY & PHYSIOLOGY

The rhomboids are a set of four muscles (two on each side) in the mid-back.  They lie deep to the trapezius muscle, but not as deep as the erector group running along each side of the spine.  Rhomboid major and minor together originate on vertebrae C7-T5 and the bottom of the ligamentum nuchae in the neck and insert on the medial edge of the scapula.

In other words, they connect the shoulder blade to the spinal column.  Together they are responsible for stabilization, retraction, elevation and inward rotation of the scapula.  The shoulder blade needs the ability to be stable with reference to the spine in all different planes of motion, as it is the anchor for many of the muscles that move the arm. For the same reason, however, it also needs the ability to perform fluid movement.  In addition, as the arm moves, it needs room in the shoulder socket for the head of the humerus, or arm bone, to move.  In order for the room to be created, the scapula, the coracoid process of the scapula (the bony protrusion of the shoulder blade in front of the shoulder) and the clavicle must all move together in a seamless motion.  Needless to say, there is a lot going on in the shoulder girdle!

There are fifteen other muscles all attached to the scapula, in addition to the rhomboids, with lines of pull in all different directions.  Given the main movements and postures that most of us engage in, the rhomboids often end up acquiescing to the “hunch club” we discussed before: pectoralis minor and subscapularis.  This can put the rhomboids in a perpetual eccentric contraction (ie “putting on the brakes”) and make them overstretched, which is why so many of us have discomfort there.  We think of them as being “tight”, but I think that word implies contracted or “the opposite of loose”, which is not quite right.  Really the muscles are often “taut”, which is more like being pulled to the point of weakness.  (I have my good friend, Ed Buresh, to thank for helping me find a better word to explain this.)  Given that these muscles are overstretched, stretching them out is not very helpful.  What really helps is strengthening them!  Here are a few basic exercises to strengthen the rhomboids, but there are many variations that work and switching it up is always the best medicine – ask your personal trainer which exercises are best for you.  As with every exercise, make sure your core is stable and you are not holding your breath (general rule: exhale on exertion).

BAND PULL-APARTS

This is a great exercise and is easy to do, even when traveling, as all you need to have with you is a band.  The bands range from “easy” to “this-thing-barely-moves-it’s-so-hard”, so you can do this exercise whether you are a novice or a serious athlete.  You simply start by holding the band out in front of you, as in photo (A).  Slowly pull the band apart using your rhomboids until your arms are out to the sides, as in photo (B).  Work your way up to two to three sets of fifteen repetitions, with rest or different exercises in between.  Some things to keep in mind:

1. Arms should be straight.  If the arms start to bend, your band is too tight – try a looser one to start.

2.  Shoulders should remain relaxed and down.  Again, if your shoulders are hunching, you are not maximizing your rhomboids.  You can either do it in front of a mirror (what my trainer forced me to do), so you can correct your shoulders if they start sneaking up, OR start with an easier band.

There is no shame in starting with the lightest band – we have to meet ourselves where we are NOW, not where we were when we were marathon running (note to self), and not where we secretly want to be.  Part of this whole process is seeing if we can get our bodies comfortable and mobile again after probably a lifetime of discomfort and immobility.  This takes time to do safely. I always revert to writing in “we” form when not giving specific “instructions” (for lack fo a better word) because I am in this process, too!  “Progress not perfection” is something I repeat to myself at least once a day but often more.  It helps 🙂

3.  The form in the photo shows the arm in medial or inward rotation, which is how we normally are, with subscapularis contracted.  In order to stretch subscapularis and strengthen the lateral rotators (infraspinatus and teres minor) instead, you can do the 2.0 version: this involves changing your hand placement so the palms are facing each other and thumbs up, or even having the palms slightly up and the thumbs slightly out to the sides.  This way as you pull out, you are in lateral rotation instead.

4.  Don’t forget your breathing.

REVERSE FLYES

There are various ways to do this one, but this is the most comfortable for me.  You hinge at the hips, with the back straight, arms down in front of you holding weights (as in the faded part of the above photo).  You lift the arms straight out to the sides, contracting the rhomboids, until they are at shoulder level.  Work your way up to two sets of twelve repetitions, with rest or different exercises in between.  Some things to keep in mind:

1. Make sure you are in a proper hip hinge with your back straight.  There should not be any flexion in your thoracic spine (in other words, the back should not be bent over in the middle).  The head should be comfortable and neutral, eyes focused on a point on the floor in front of you.  If you need to look up into the mirror in front, do so for one rep, but then make sure to put your head back into neutral position.

2. That said, there shouldn’t be too much extension or arch in the back, either.  You need to be forward enough to actually engage your mid-back;  otherwise, you are engaging the wrong muscles.  In other words, it’s NOT this (see the area in yellow?  That’s mainly the middle deltoid that is being worked here, not the rhomboids):

3.  There are many variations you can do:  with different objects (although the objects should be heavy enough to feel challenging after twelve reps), with bands or on an incline bench if that’s more comfortable for the back.  See the photos below.

 

4.  Don’t forget your breathing.

 

ROWS

Rows target multiple muscles, including rhomboids, and can be done seated or standing.

The seated row (photos above): begin by sitting on the bench and grasping the cable grip attachment. Sit upright, straighten your lower back and slide your hips back slightly. As you pull the attachment toward your waist, pull your shoulders back and squeeze your shoulder blades together.  Hold that squeeze for an extra second to activate the rhomboids more specifically.  Work up to three sets of twelve repetitions, with rest or different exercises in between.  Remember to keep your back straight and to breathe.

The bent-over dumbbell row (photos above):  Set up in the same manner as you would for the reverse flyes above.  You can hold the weights with palms facing one another or palms up as in the photo above.  Rather than moving arms out to the sides as in the reverse flyes, for this exercise you simply bend your elbows and pull your arms straight back until your wrists are at your sides.  In order to activate the rhomboids more specifically, squeeze the shoulder blades together at the top of the movement and hold for an extra second.  Work your way up to three sets of twelve repetitions, with rest or different exercises in between.  Remember to keep your back straight, head neutral and breathe.

In the next post, we will highlight the upper trapezius muscle, another muscle which often gives people discomfort.  Like the rhomboids, there is great evidence suggesting that strengthening rather than stretching this muscle leads to relief.  Stay tuned 🙂

 

**BONUS EXERCISES**

FOR THE ATHLETES OR PEOPLE WORKING WITH TRAINERS (ONLY):

T-BAR ROWS

My trainer used to love this one – mostly for latissimus dorsi and teres minor, but it works the rhomboids as well.  Please do not try this exercise for the first time without a trainer.  Again, it’s a hip hinge with the back straight.  This time the angle of the back to the floor is slightly larger, so you are able to look forward with the head still in neutral.  The weight is shifted back onto the glutes.  Start in the position in the first photo with the bar on the ground, and lift until the bar is at your chest as in the second photo.  As you lift, your upper body lifts slightly as well (notice the difference between her body placement in the two photos).  The great thing about this exercise is that it works many of the posterior chain muscles from back to legs.

BENT OVER BARBELL ROWS

This is another good one to work many of the muscles in the back.  Again, please do not try this one for the first time without a trainer’s supervision.  You can do it with a backwards grip or split grip, but I like the palm-forward grip like in the photo.  Again, you hinge slightly at the hips, keeping the back straight and head in neutral.

 

 

Filed Under: Best Practices

June 15, 2018 by Julieta Benavides

The Chin Tuck: Daily Exercise #1

Neck and shoulder pain are among the most common complaints reported by new clients. Recent developments in pain science have largely debunked purely structural models as explanations for pain.  However, structural analysis is still relevant as a piece of a larger paradigm, particularly when it comes to the neck and shoulders.  So while biomechanics may not be everything, in most cases of neck and shoulder complaints, consistent forward head posture greatly contributes to the root cause of the pain.  In some of these cases, there is an accompanying uncomfortable “dowager’s hump” at the base of the neck that forms when the vertebrae become compressed.  Neurological overstimulation can also result from sustained tension in the suboccipital muscles on the first two cervical vertebrae, causing headaches, anxiety, dizziness and other related symptoms.  Additionally, jutting the head forward places incredible tension on the muscles below the jaw, as the body is using the jaw to pull back on, and counter the weight of, the head.  This can manifest as neck tension or TMJ.  Given that many of our daily activities involve staring straight ahead, it’s not a surprise that our heads tend to gradually lean forward on our necks rather than sitting upright fully supported by the spine.

  

A simple chin tuck can gradually reverse this development, and it actually feels great to do.  I show this exercise to almost all of my clients, and I do it daily myself, particularly when I find myself hunched over the wheel while driving.  Tucking the chin elongates the muscles in the back of the neck and can relieve nerve compression by creating more space on the back side of the vertebrae, where the nerves exit.  This position can relax the jaw and the front of the neck, too, particularly if you use your finger to support your jaw. The most basic version involves simply backing up your head and rotating it slightly forward so you are tucking your chin into your neck.  You will end up with a “double chin” type of effect.  You should feel a pleasant stretch at the back of your neck.  If you are chronically in forward head posture, you might even feel a rush of sensation up your neck and into your head.  If it feels easier, you can use your finger to push your head back.  It looks like this:

   

 

You can also stand with your back up against a wall, with your feet resting up to 12 inches away from the bottom of the wall.  When you tuck your chin, you can aim to rest the back of your head against the wall, slightly moving your head up along it.  If you are still having trouble, you can start out doing this exercise while lying down in a supine, or face up, position.  You can hold the Chin Tuck for 5-20 seconds and repeat it 5-10 times throughout the day.  Pay attention to your shoulders and ribcage while you do this;  they should remain neutral.  If you find yourself raising your shoulders or flaring your ribcage up, reset your body and try it against the wall or lying down until you can keep those in a more neutral position. I learned an advanced version of the Chin Tuck from one of Erik Dalton‘s newsletters a few months ago and I love the added benefits!  So, when you are ready for 2.0, you can add a little myofascial drag to your Chin Tuck.  Simply place your hand gently on your sternum, so that your thumb is on the innermost part of the clavicle on one side and your fingers are on the innermost part of the clavicle on the opposite side. Place your other hand on top of that hand, and as you tuck your chin, you drag the skin slightly downward.  This creates even more of a stretch in the anterior neck muscles. The steps look like this:

The final step is to hold the myofascial drag, turn your head to the left, tuck your chin, and then repeat on the other side.  If you want to follow along to a visual, I made this incredibly dorky video since I couldn’t find any on the internet:  Chin Tuck Video

After a few months of doing this exercise, most clients report a decrease in neck and shoulder tension.  Honestly, I attribute this at least partially to better body awareness, as doing this exercise makes it evident how far forward we are normally carrying our heads.  It also makes us pay attention to how uncomfortable the forward head position is and how much better the head feels on top of the spine instead of in front of it.

Filed Under: Best Practices

March 8, 2018 by Julieta Benavides

Shoulder Mobility in Baby Steps

In a perfect world, the shoulder would be one of the most mobile regions in our bodies.  It is comprised of the shoulder (or glenohumeral) joint, the space where the arm connects to the body, and the shoulder (or pectoral) girdle, which includes the collarbone, the shoulder blade and their surrounding muscles.  In both of these areas, there is great opportunity for movements in all planes of motion.  However, despite the possibilities available in the anatomical “best case scenario”, the majority of us suffer from a general lack of flexibility in this region.  Of course, each person has individual reasons for this and they are often multifactorial.  However, one of the most common factors contributing to this decreased range of motion is too much time spent in static postures or a narrow range of repetitive movements.  Being hunched over isn’t necessarily “the problem” – it’s being constantly hunched over for hours and hours without switching it up.  Studies have shown that what is generally considered “good posture” has very little correlation with a lack of pain in the shoulder region (or anywhere, actually).  Just as standing 100% of the time is not the fix for the discomfort caused by continual sitting, throwing your shoulders back and sticking your chest out 100% of the time is not the solution for hunching.  Variety, as they say, is the spice of life.  My clients who work at computers will inevitably spend a large part of their day with their arms in front of them, rotated inwardly, just as I will inevitably spend much of my day with my arm rotated so that I can put my forearm on a client’s body in front of me.  We need to accept that SOME of these postures are unavoidable consequences of our biomechanical environment, but we have agency over how much movement we can sneak in even within limitations.  If we are mindful of performing a variety of opposing movements, we can avoid some of the discomforts and range of motion issues experienced by our modern lifestyles.  One simple way to focus on this is to periodically lengthen the muscles that become continually contracted through daily living.  Stretching a muscle will not necessarily produce any permanent changes in muscle length, but introducing motion in a different direction can ultimately increase the range of motion.  From my clinical experience, two of the main muscles that could benefit from this temporary lengthening on almost everyone are pectoralis minor and subscapularis, both in the shoulder region.

 

Pectoralis minor:

Pec minor is a small but very important muscle in the chest region.  It originates on the surfaces of the third, fourth and fifth ribs and attaches to the coracoid process of the scapula, which is the little hook-like structure of the shoulder blade which sticks out on the front of the body.  It pulls the shoulder blade medially, forward and down.  In other words, when it contracts we end up in the “hunch” position. Click here for a 30-second video of pectoralis minor in action.  Since many of us end up in this position chronically, it’s helpful to alternate our computer work / driving / massaging with short bouts of lengthening.  The doorway stretch is excellent for accomplishing this and can be done any time we pass through doorway, or, for example, every time we get up to get water or on our way back from the restroom.  Here is Brent Brookbush demonstrating proper form for this stretch:

Subscapularis:

Subscapularis is another muscle which can easily become chronically contracted.  It is the internal muscle of the rotator cuff, originating on the interior surface of the shoulder blade (the part against the ribcage that we can’t normally touch) and attaching to the humerus of the arm.  Other than the stabilizing function of the rotator cuff muscles as a group, subscapularis is responsible mainly for rotating the arm medially, or inward.  Video here.  Hunch posture starting to sound familiar?  Performing a broomstick stretch once in a while to lengthen this muscle is an easy way to counteract that habit.  I like Dr. Mandell’s version:

We may not be able to incorporate constant gentle movement into every moment of our days.  If we have desk jobs, we are going to sit a lot and perhaps hunch a lot.  The important thing is to try to switch it up when we can.  These are but two easy ways to do that.  Of course, you could also get your massage therapist to help you release these muscles too 🙂

Filed Under: Anatomy, Best Practices

December 12, 2017 by Julieta Benavides

Why You Still Need A Doula Even If You Have A Midwife And Partner

Midwives and doulas have become slightly more mainstream in the U.S. over the past few decades, but there is still much confusion as to what exactly their roles are.  Women often ask why they need a doula if they are planning to have a midwife. Another common question is why they would need a doula if their romantic partner is planning to be the birth companion during labor.  The truth is that each of these people have a specific and important role to inhabit during the birthing process and these roles are very different.

A midwife is a medical professional, much like an OB/GYN solely in terms of her ROLE in pregnancy and labor.  A midwife is trained through years of schooling to provide any necessary medical care during pregnancy and her license authorizes her to catch the baby when it comes time for labor.  (Not to be weird, but I don’t like using the expression “deliver the baby” because the mother is the one delivering the baby … not the doctor or midwife.  Even through the language we use, I think the power should stay where it belongs, with the mom.)   Certified nurse-midwives can do many of the same things as doctors, meaning they can perform gynecological exams, provide prenatal care, administer pain medications, give labor-inducing drugs, monitor the fetus using electronic equipment and perform an episiotomy and stitch tears. Here is where the similarities with modern obstetrics end, however.  Midwifery, in contrast to the medicalized model of birth, is woman-centered.  It produces birth professionals with expertise and skills in supporting women to maintain healthy pregnancies, have optimal births and have the most favorable recoveries during the postpartum period. Here is a statement from the Midwives Alliance North America:

“The Midwives Model of Care™ is a fundamentally different approach to pregnancy and childbirth than contemporary obstetrics. Midwifery care is uniquely nurturing, hands-on care before, during, and after birth. Midwives are health care professionals specializing in pregnancy and childbirth who develop a trusting relationship with their clients, which results in confident, supported labor and birth. While there are different types of midwives practicing in various settings, all midwives are trained to provide comprehensive prenatal care and education, guide labor and birth, address complications, and care for newborns. The Midwives Model of Care™ is based on the fact that pregnancy and birth are normal life events. The Midwives Model of Care includes:

  • monitoring the physical, psychological and social well-being of the mother throughout the childbearing cycle
  • providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
  • minimizing technological interventions and
  • identifying and referring women who require obstetrical attention.

The application of this model has been proven to reduce the incidence of birth injury, trauma, and cesarean section.”

In contrast to a midwife, a doula is not a medical professional, but her role is just as important.  A birth doula is basically a birth coach, trained in all sorts of non-medical techniques to help a laboring mom feel safe and empowered throughout the experience.  Doulas provide continual, uninterrupted support during the length of the labor, responding to mom’s physical, mental and emotional needs as they arise.  A doula is always asking herself “What is going on for mom at this stage of her labor and how can I best support her?”  This can come in the form of physical support:  providing comfort measures for pain management, such as massage, hot packs, ice packs, or breathing exercises, and even reminding mom that she might need to eat, use the bathroom or simply rest.  One of the most important ways in which a doula can provide physical support is by suggesting position changes based on where the baby is in the pelvis or if a position is not producing any progress.  The majority of unplanned cesareans are performed due to “failure to progress,” which means the baby essentially gets temporarily stuck in the pelvis, and the doctor either doesn’t have the time or doesn’t know how to help mom and baby get into a more favorable position for descent.  If mom is encouraged to move, squat, perform a lunge, allow an “abdominal lift” or a side-lying release for a few contractions, it often provides just that extra little bit of space so baby can wiggle his or her way down further in the pelvis.  This provides a feeling of accomplishment for mom and less birth trauma for baby.

Mental support from a doula might involve coaching mom through visualization exercises, or explaining what could be happening at any given time so mom or her partner can better advocate for themselves.  Preserving the memory of the birth is another way in which a doula provides mental support, as she can often fill in fuzzy details for the new parents later during the postpartum visit.  Finally, a doula provides emotional support through constant reassurance and encouragement. She takes charge when mom loses her rhythm until mom can get it back.  If mom loses faith in herself for a moment, a doula is there to remind her that she is strong enough to deliver her baby.  Often what is needed is some sort of change, whether it be positional or environmental, and a doula can provide knowledgeable guidance.  After birth, postpartum doulas help a new mother as she recovers from the birthing process. This includes caring for the infant and guiding a mother through the breast-feeding process.

Benefits of having a doula:

 

A birth partner (husband, wife, partner, etc) has a large supportive role during labor, but unlike a doula, lacks the specific training to help mom with position changes and pain management techniques.  A doula will often coach the partner in how to better support the laboring mom, so rather than the doula being the focus, the focus can be on the bond between mom and her partner.  As the partner has a very personal investment in the birth process, s/he might get anxious or overwhelmed and be unable to help mom effectively.  A doula has the professionalism and experience to handle emotional situations with a sense of calm, and can often step in to provide the necessary support until the partner can once again participate.  A doula can be helpful for the partner as well as for the birthing mom.

The childbirth year is a time of a woman’s life during which she should have an abundance of  support.  A doula, in addition to a midwife and labor partner, can play an integral part in helping a laboring mom to feel as empowered as possible and to have a more positive birth experience.

 

RESOURCES:

DONA International

Midwives Alliance North America

 

 

Filed Under: Best Practices

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